Study patients
This study was conducted by retrospectively reviewing clinical data from a total of 58 children patients with HS who were diagnosed at the Children’s Hospital of Chongqing Medical University from January 2015 to December 2019. Our study was approved by the ethics committee of the Children’s Hospital of Chongqing Medical University (No: 2020-288), and informed consent was obtained to review patient medical records. We excluded one patient with splenectomy because follow-up data were lacking, leaving 57 patients for the study. All children presented with an enlarged spleen. All eligible patients were assessed according to the BCSH 2011 guidelines and European Hematology Association 2017 guidelines2,3, while only patients with moderate, severe HS or impact daily life were operated on. Grouping was based on treatment intention 41 patients had undergone total splenectomy (median age 9, range 2–17 years) and 16 patients had undergone SPSE (median age 7 years, range 5–11 years). All patients or guardians were informed about the advantages and disadvantages of the procedure and received a written informed consent prior to surgery.
SPSE surgery procedure
We performed selective embolization of the splenic segmental artery based on the unique anatomy of the spleen and splenic artery by analyzing the distribution of the splenic segmental artery by means of splenic artery trunk angiography. At the same time, the degree of embolization was judged by the intraoperative flow velocity of the embolized artery. The degree of embolization was determined according to a slight slowing of the flow as 30% to 40%, a marked slowing as 50% to 60%, a peristaltic advance after briefly stopped as 70% to 80%, a marked regurgitation as 90% and above. The extent of splenic embolism was predicted by the above two aspects. The specific surgical procedure is as follows:
First, splenic arteriogram procedure. The patients were placed in the supine position, a 4Fr introducer sheath (RS*A40G07SQ, TERUMO) was inserted through the right common femoral artery by using the Seldinger technique and a 4Fr catheter (RF*ZB54110, TERUMO) was passed through the main trunk of the splenic artery for imaging. Based on the visualization of the splenic vessels, adopting secondary artery in the lower and middle spleen as the target vessel, the arterial embolization, which was confirmed by contrast, was performed by a 2.7 Fr microcatheter (MC-PE27131, TERUMO) to super-select the grade 2-3 arterial branches.
Second, configuration of embolic agents. Mixing polyvinyl alcohol granules (PVA-500, COOK)1g and lodixanol320 (GE Healthcare Ireland)5ml thoroughly, extract 2ml of suspension and add 0.25g of triple cephalosporin, then add the appropriate amount of contrast agent to make a total of 15 ml of embolic agent.
Third, embolization procedure. The embolization area was mainly in the middle and lower spleen, preserving most of the upper spleen and the splenic hilum. After completion of embolization, the degree of embolization was determined again by imaging of the main trunk of the splenic artery. If the embolic scope was insufficient, additional embolization operations can be performed until the embolic scope reaches 70%-85%. Sterile gauze and pressure were applied to the puncture site for hemostasis followed by bandaging and braking for 6-8 hours. The operation time only require 30 minutes maximum. The patency of splenic vein flow was detected by vascular ultrasound 3 days after surgery, and third-generation cephalosporin was applied by intravenous prophylactic in 48 hours after surgery.
Data collection and follow-up
We collected preoperative and postoperative examination data of patients who underwent total splenectomy and SPSE, with a minimum 6-months follow-up. The last follow-up was in September 2020. The patients underwent computed tomography (CT) scan using a 64-channel multidetector CT system (Lig_x0002_htspeed VCT, GE Medical systems, USA). Splenic volume were analyzed by Volume Rendering function with the philips intellispace portal software platform, version 6.0.1.20700.
Statistical methods
Statistical analyses were performed using the SPSS software version 22.0. Measurement data were expressed as mean ± standard deviation (± sd) and analyzed by Student’s t -test. Enumeration data were expressed as rate (%), and Chi-square test was adopted. Comparison of laboratory parameters after splenic artery embolization was carried out using the paired t-test, the Wilcoxon signed ranks test, the Mann-Whitney U test, or the chi-square test. Statistical significance was defined as P < 0.05.